Skip to main content

Advertisement

SpringerLink
Log in

The endonasal midline inferior intercavernous approach to the cavernous sinus: technical note, cadaveric step-by-step illustration, and case presentation

  • Technical Note - Neurosurgical Anatomy
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Purpose

Traditional endoscopic endonasal approaches to the cavernous sinus (CS) open the anterior CS wall just medial to the internal carotid artery (ICA), posing risk of vascular injury. This work describes a potentially safer midline sellar entry point for accessing the CS utilizing its connection with the inferior intercavernous sinus (IICS) when anatomically present.

Methods

The technique for the midline intercavernous dural access is described and depicted with cadaveric dissections and a clinical case.

Results

An endoscopic endonasal approach exposed the periosteal dural layer of anterior sella and CS. The IICS was opened sharply in midline through its periosteal layer. The feather knife was inserted and advanced laterally within the IICS toward the anterior CS wall, thereby gradually incising the periosteal layer of the IICS. The knife was turned superiorly then inferiorly in a vertical direction to open the anterior CS wall. This provided excellent access to the CS compartments, maintained the meningeal layer of the IICS and the medial CS wall, and avoided an initial dural incision immediately adjacent to the ICA.

Conclusion

The midline intercavernous dural access to the CS assisted by a 90° dissector-blade is an effective modification to previously described techniques, with potentially lower risk to the ICA.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Copyright Mayo Clinic, used with permission of Mayo Foundation for Medical Education and Research, all right reserved. AICS anterior intercavernous sinus, CS cavernous sinus, ICA internal carotid artery, IICS inferior intercavernous sinus, PCP posterior clinoid process, PG pituitary gland, Tub. tuberculum

Fig. 3
Fig. 4

Copyright Mayo Clinic, used with permission of Mayo Foundation for Medical Education and Research, all right reserved. CS cavernous sinus, ICA internal carotid artery, IICS inferior intercavernous sinus, PG pituitary gland

Abbreviations

AICS:

Anterior intercavernous sinus

CCL:

Caroticoclinoidal ligament

CN:

Cranial nerve

CS:

Cavernous sinus

ICA:

Internal carotid artery

IICS:

Inferior intercavernous sinus

IPL:

Inferior parasellar ligament

MR:

Magnetic resonance

PG:

Pituitary gland

References

  1. Almeida JP, Workewych A, Takami H et al (2020) Surgical anatomy applied to the resection of craniopharyngiomas: anatomic compartments and surgical classifications. World Neurosurg 142:611–625. https://doi.org/10.1016/j.wneu.2020.05.171

    Article  PubMed  Google Scholar 

  2. Beer-Furlan A, Priddy BH, Jamshidi AO et al (2020) Improving function in cavernous sinus meningiomas: a modern treatment algorithm. Front Neurol 11:652. https://doi.org/10.3389/FNEUR.2020.00652/FULL

  3. Chenin L, Toussaint P, Lefranc M, Havet E, Peltier J (2021) Microsurgical anatomy of the inferior intercavernous sinus. Surg Radiol Anat 43(2):211–218. https://doi.org/10.1007/S00276-020-02581-W

    Article  PubMed  Google Scholar 

  4. Dhandapani S, Singh H, Negm HM, Cohen S, Anand VK, Schwartz TH (2016) Cavernous sinus invasion in pituitary adenomas: systematic review and pooled data meta-analysis of radiologic criteria and comparison of endoscopic and microscopic surgery. World Neurosurg 96:36–46. https://doi.org/10.1016/j.wneu.2016.08.088

    Article  PubMed  Google Scholar 

  5. Fernandez-Miranda JC, Gardner PA, Rastelli MM et al (2014) Endoscopic endonasal transcavernous posterior clinoidectomy with interdural pituitary transposition: technical note. J Neurosurg 121(1):91–99. https://doi.org/10.3171/2014.3.JNS131865

    Article  PubMed  Google Scholar 

  6. Fernandez-Miranda JC, Gardner PA, Rastelli MM et al (2014) Endoscopic endonasal transcavernous posterior clinoidectomy with interdural pituitary transposition: technical note. J Neurosurg 121(1):91–99. https://doi.org/10.3171/2014.3.JNS131865

    Article  PubMed  Google Scholar 

  7. Kosty J, Peterson R, Miriyala S et al. An anatomic assessment of the intercavernous sinuses and review of the literature. J Neurol Surg Part B Skull Base. Published online June 6, 2022. https://doi.org/10.1055/a-1819-0144

  8. Martinez-Perez R, Silveira-Bertazzo G, Carrau RL, Prevedello DM (2020) The importance of landmarks in endoscopic endonasal reinterventions: the transpterygoid transcavernous approach. Acta Neurochir (Wien) 162(4):875–880. https://doi.org/10.1007/s00701-019-04206-7

    Article  Google Scholar 

  9. Nishioka H, Ukuhara N, Horiguchi K, Yamada S (2014) Aggressive transsphenoidal resection of tumors invading the cavernous sinus in patients with acromegaly: predictive factors, strategies, and outcomes: clinical article. J Neurosurg 121(3):505–510. https://doi.org/10.3171/2014.3.JNS132214

    Article  PubMed  Google Scholar 

  10. Omar AT, Munoz DG, Goguen J et al (2021) Resection of the medial wall of the cavernous sinus in functioning pituitary adenomas: technical note and outcomes in a matched-cohort study. Clin Neurol Neurosurg 200:106306. https://doi.org/10.1016/J.CLINEURO.2020.106306

    Article  Google Scholar 

  11. Rejane-Heim TC, Silveira-Bertazzo G, Carrau RL, Prevedello DM (2021) Surgical anatomy and nuances of the expanded endonasal transdorsum sellae and posterior clinoidectomy approach to the interpeduncular and prepontine cisterns: a stepwise cadaveric dissection of various pituitary gland transpositions. Acta Neurochir (Wien) 163(2):407–413. https://doi.org/10.1007/s00701-020-04590-5

    Article  Google Scholar 

  12. Rhoton AL, Harris FS, Renn WH (1977) Microsurgical anatomy of the sellar region and cavernous sinus. Clin Neurosurg 24:54–85. https://doi.org/10.1093/neurosurgery/24.cn_suppl_1.54

    Article  PubMed  Google Scholar 

  13. Truong HQ, Lieber S, Najera E, Alves-Belo JT, Gardner PA, Fernandez-Miranda JC (2019) The medial wall of the cavernous sinus. Part 1: surgical anatomy, ligaments, and surgical technique for its mobilization and/or resection. J Neurosurg 131(1):122–130. https://doi.org/10.3171/2018.3.JNS18596

    Article  Google Scholar 

  14. Tubbs RS, Griessenauer C, Loukas M, Cohen-Gadol AA (2014) The circular sinus: an anatomic study with neurosurgical and neurointerventional applications. World Neurosurg 82(3–4):E475–E478. https://doi.org/10.1016/J.WNEU.2012.11.052

    Article  PubMed  Google Scholar 

  15. Wahl L, Lockwood JD, Keet K et al (2020) The inferior intercavernous sinus: an anatomical study with application to trans-sphenoidal approaches to the pituitary gland. Clin Neurol Neurosurg 196:106000. https://doi.org/10.1016/J.CLINEURO.2020.106000

  16. Zhang Q, Wang Z, Guo H et al (2019) Direct Transcavernous sinus approach for endoscopic endonasal resection of intracavernous sinus tumors. World Neurosurg 128:e478–e487. https://doi.org/10.1016/j.wneu.2019.04.182

    Article  PubMed  Google Scholar 

Download references

Funding

This work was supported in part by funds from the Johnson Endowed Professorship and Joseph and Barbara Ashkins Endowed Professorship in Surgery.

Author information

Authors and Affiliations

  1. Department of Neurologic Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA

    Rima S. Rindler, Luciano C. Leonel, Stephen Graepel, Edoardo Agosti, Panagiotis Kerezoudis, Carlos D. Pinheiro-Neto & Maria Peris-Celda

  2. Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA

    Rima S. Rindler, Luciano C. Leonel, Edoardo Agosti, Panagiotis Kerezoudis, Carlos D. Pinheiro-Neto & Maria Peris-Celda

  3. Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN, USA

    Carlos D. Pinheiro-Neto & Maria Peris-Celda

Authors
  1. Rima S. Rindler
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Luciano C. Leonel
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Stephen Graepel
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Edoardo Agosti
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Panagiotis Kerezoudis
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Carlos D. Pinheiro-Neto
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Maria Peris-Celda
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conceptualization: Maria Peris-Celda, Carlos Pinheiro-Neto; methodology: Maria Peris-Celda, Rima Rindler; formal analysis and investigation: Rima Rindler, Luciano Leonel, Edoardo Agosti; writing—original draft preparation: Rima Rindler, Panagiotis Kerezoudis, Stephen Graepel; writing—review and editing: Maria Peris-Celda, Carlos Pinheiro-Neto; funding acquisition: Maria Peris-Celda; resources: Luciano Leonel, Edoardo Agosti, Stephen Graepel; supervision: Maria Peris-Celda, Carlos Pinheiro-Neto.

Corresponding author

Correspondence to Maria Peris-Celda.

Ethics declarations

Ethics approval

Approval was obtained from the ethics committee of the Mayo Clinic. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.

Consent for publication

Patients signed informed consent regarding publishing their data.

Conflict of interest

The authors declare no competing interests.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Neurosurgical Anatomy

Previous presentations: This work was accepted as an oral presentation at the 31st North American Skull Base Society meeting in February 18–20, 2022, Phoenix, AZ.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (MP4 31277 KB) Intraoperative video demonstrating the midline endoscopic endonasal inferior intercavernous sinus approach for biopsy of a lesion in the left cavernous sinus.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rindler, R.S., Leonel, L.C., Graepel, S. et al. The endonasal midline inferior intercavernous approach to the cavernous sinus: technical note, cadaveric step-by-step illustration, and case presentation. Acta Neurochir 164, 2573–2580 (2022). https://doi.org/10.1007/s00701-022-05284-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-022-05284-w

Keywords

Search

Navigation